1. Medical Records Management
Chapter 14
Medical Records Management

2. Medical Records Management and the TPMS
[FIGURE 14-1]

3. Purpose of Medical Records
Provide base for managing patient care
Provide interoffice and intraoffice communication as necessary
Determine any patterns that surface to signal provider of patient needs

4. Purpose of Medical Records
Serve as basis for legal information to protect providers, staff, patients
Provide clinical data for research

5. Ownership of Medical Records
Property of those who create record
Information belongs to patient and is protected with privacy and confidentiality
Patients are allowed access to their medical records and can ask certain information be added or excluded from their file

6. Ownership of Medical Records
Providers who include their patients in their medical record keeping foster trust and respect with their patients

7. Authorization to Release Information
Before information released from medical record, patient notified and written approval received
Identify reason for release and what information specifically requested
Only that information released
Does not include release of information to patient’s chosen insurance carrier

8. Manual or Electronic Medical Records
Americans to have EHRs by 2014
Planned projects: transmitting x-rays and laboratory results electronically
2011: Electronic prescribing (e-prescribing) of medications for Medicare

9. Manual or Electronic Medical Records
Advantages
Currently established and understood
Easier to protect confidentiality
No worry of computer malfunction

10. Manual or Electronic Medical Records
Disadvantages
Can be used by only one person at a time
Easily misplaced or misfiled
Equipment and storage space required
More susceptible to error

11. Manual or Electronic Medical Records
Advantages
Multiple users possible
Not easily misplaced or misfiled
Errors less likely
Patterns and data more easily accessed
Quickly available in emergencies
Office storage space not required
Legible, organized patient documentation
Improved medication management
Improved quality of care

12. Manual or Electronic Medical Records
Disadvantages
Need protection to prevent loss of data
Expensive to establish and maintain
May require on-site assistance
Can require up to 12 weeks for staff to prove productive

13. Manual or Electronic Medical Records
2009: American Reinvestment and Recovery Act (ARRA)
Incentives for physicians and hospitals to make transition to EMR
Solo practitioners least likely to use EMRs
EMRs grow faster in larger, multi-provider clinics
Medical record system must fit facility

14. The Importance of Accurate Medical Records
Accuracy essential to patient care
Critical to facility’s smooth functioning
Important when referring patient to outside specialists
Essential in controlling costs
May be needed in medical litigation

15. The Importance of Accurate Medical Records
Creating paper and electronic charts
Chart prepared on or before day of patient’s first visit
Paper medical records require assembly of appropriate file folders and forms
Electronic medical charts prepared in much the same manner except that all information stored electronically
(See Procedure 14-1: Establishing a Paper Medical Chart for a New Patient)
(See Procedure 14-2: Registering a New Patient Using Medical Office Simulation Software)

16. The Importance of Accurate Medical Records
Correcting medical records
Paper medical record
Draw single line using red ink pen through error
Make correction
Write Corr. or Correction above area corrected
Indicate your initials and current date
Never obliterate
Forensic experts able to determine when and how corrections were made
(See Procedure 14-3: Correcting a Paper Medical Record)

17. The Importance of Accurate Medical Records
Correcting medical records
Errors in EMRs
Draw line through error (using “tracking” device in word processing software)
Correction made immediately after information lined out
“Corr.” or “Correction” indicated with your initials and date correction made
EMR software locks out chart additions after specified time
(See Procedure 14-4: Updating Patient Registration Information Using Medical Office Simulation Software (MOSS))

18. The Importance of Accurate Medical Records
Correcting medical records
If information or chart sent elsewhere, make copy of corrected information and send it as quickly as possible

19. Types of Medical Records
Problem-oriented medical records (POMRs)
Vital identification data, immunizations, allergies, medications, problems
Identified by a number that corresponds to charting relevant to that problem number
Each problem followed with the SOAP(ER) approach for all progress notes

20. Types of Medical Records
Problem-oriented medical records (POMRs)
S: Subjective impressions
O: Objective clinical evidence
A: Assessment or diagnosis
P: Plans for further studies, treatment, management
E: Education for patient
R: Response of patient to education and care given

21. Types of Medical Records
Problem-oriented medical records (POMRs)
Internists, family practitioners, pediatricians use POMR system
Used in manual medical records as well as EMRs
Various formats for POMR manual charts

22. Types of Medical Records
Source-oriented medical records (SOMRs)
Groups information according to its source
Makes different types of information quickly accessible
Many providers use SOAP(ER) method to record their chart notes
SOMR does not have problem list
Many EMR software packages use POMR or SOMR format

23. Types of Medical Records
Strict chronological arrangement
Data filed strictly with most recently charted materials to top of folder
Difficult for provider or MA to quickly assess patient’s clinical picture
May fit specialty office where patients seen on short-term basis

24. Equipment and Supplies
Vertical files
Open-shelf lateral files
Movable file units
Open-shelf lateral file cabinet >>
File folders
Identification labels
[FIGURE 14-3]

25. Equipment and Supplies
Guides and positions
Out guides
An out guide indicating name of person who has possession of the file >>
[FIGURE 14-6]

26. Basic Rules for Filing
Alphabetizing is key to organizing files and charts
Indexing rules developed by Association of Medical Records Administrators (AMRA)

27. Basic Rules for Filing Indexing units Filing identical names
Unit identifies each part of a name
Each unit identified according to unit 1
Applied to individual names, organizations, clinics
Filing identical names
When names identical, address may be used to order files
Preferred methods include date of birth or Social Security number

28. Steps for Filing Medical Documentation in Patient Files
Inspect
Index
Code
Sort
File

29. Filing Techniques and Common Filing Systems
Color-coding technique used in three major filing systems
Patient charts use alphabetic system of color coding
Color coding can be used in numeric filing
Color coding makes retrieval of files more efficient

30. Filing Techniques and Common Filing Systems
Color coding
Tab-Alpha system
Alpha-Z system
Customized color coding systems
Colored File folders by first name
Colored File folders by last name
Color-coded numbers

31. Filing Techniques and Common Filing Systems
Alphabetic filing
Simplest filing methods; strictly maintained by assigning label to each file
Numeric filing
Organized by number rather than by letter
Preserves patient confidentiality
Straight numeric
Terminal digit
Middle digit
(See Procedure 14-5: Steps for Manual Filing with an Alphabetic System)
(See Procedure 14-6: Steps for Manual Filing with a Numeric System)

32. Filing Techniques and Common Filing Systems
Components of numeric filing
Serially numbered dividers with guides
Miscellaneous (general) numeric file section
Alphabetic card file
Accession record

33. Filing Techniques and Common Filing Systems
Subject filing
Convenient for locating frequently used services or for filing reference materials for patient needs
Choosing a filing system
Facility primary objectives with storage of patient files, business records, research files
Selecting alphabetic or numeric system
Confidentiality of charts
HIPAA compliant
(See Critical Thinking box)

34. Filing Procedures Cross-referencing
Store files for quick and accurate retrieval
Especially helpful with foreign names, hyphenated names, stepfamilies
Does not need to be elaborate
Steps for cross-referencing
(See text for steps and examples)

35. Filing Procedures Tickler files
Reminder that some action needs to be taken at date in future
Can be accomplished manually or electronically
Should contain the following:
Patient name
Tickler date when action should be taken
Required action
Additional relevant information

36. Filing Procedures Release marks Checkout system Provider’s initials
Quality-control measure
Checkout system
Out sheets or out guides for use when chart removed
List of information that should be included on out sheet

37. Filing Procedures Locating missing files or data
Conduct systematic search
Steps to searching
Check files for proper filing order whenever returning or retrieving file folder
When finished with a record, refile it immediately

38. Filing Procedures Filing chart data Types of reports Clinical notes
Correspondence
Laboratory reports
Miscellaneous

39. Filing Procedures Retention and purging Record purging Active files
Inactive files
Closed files
(See Table 14-2: Records for Retention)

40. Correspondence Filing procedures for correspondence
Remove paper clips and staple items together
Inspect to see if item is ready to be filed
On incoming correspondence, be sure letterhead is related to letter

41. Correspondence Filing procedures for correspondence
On outgoing correspondence, look at inside address and reference line
On incoming or outgoing correspondence, code indexing units of designated label
Create miscellaneous folder for items that do not have enough in number to warrant individual folder

42. Electronic Medical Records
Mandated; one day will replace all paper/manual medical records
Fewer errors created
Create, store, edit, retrieve patient data
Allow more than one person to access chart at same time

43. Electronic Medical Records
Purchased as single computer application or part of larger practice management system
EMR capability list
Providers use computers to open and view charts and write prescriptions
System administrators can identify access and privileges for confidentiality
EMR fully recognized as legal document

44. Archival Storage
Providers preserve patient medical records for life of practice
Computers help to solve space issues through EMRs
Records copied onto optical disks or CDs
Should have backup system

45. Archival Storage Transfer of data
EMRs easily ed in whole or in part
Faxing
Scanners (optical character recognition)

46. Archival Storage Confidentiality
Major issue in using computer and online devices for storage and transfer of medical information
Never discuss information outside clinic
Unwise to discuss private information within facility if it is not your concern